Discussions By Condition: I cannot get a diagnosis.

I'm Just an ICU Doc! This newbie needs diagnostic help. (Is this the correct forum?)

Posted In: I cannot get a diagnosis. 1 Replies
  • Posted By: ICU DOC
  • January 5, 2009
  • 10:23 PM

A previously healthy 30 y.o. female noticed left perianal discomfort 36 hrs post anal intercourse (and 12 hours post digital anal insertion). Has frequent, uneventful anal sex, with and without lubrication. Denies ever having vaginal or anal discharge, bleeding or pain. Boyfriend only sexual partner last two years. Symptoms -ve for tenesmus, hematochezia, fever, chills or h/o similar symptoms, recent illness or hemorrhoids. No h/o STD, diverticulosis, IBD or IBS. Pain and tenderness has worsened slightly over 3 days. Worse after long periods sitting, and upon waking each morning. Limited to left perianal area. Describes as "discomfort", though has occasional sharp pains with change in body position. Only mildly increased pain during defecation; no urgency, constipation or diarrhea. No pruritis. Vague as to pain constancy, or if awakened from sleep. Today, noticed toilet paper pink after dabbing anal area (no bowel movement), and had mild dysuria. Denies hematuri or discharge.
Other PMH negative.

O/E Afebrile. Well-looking.
No inguinal lymphadeopathy. Pubic area unshaven.
Linear 1 cm tendon-like swelling extending radially at 4 oclock position. Quite firm. Non fluctuant. Some overlying tenderness and mild erythema. No obvious fissures, tags, hemorrhoids or folliculitis.
Refused rectal exam.
24 hr. repeat exam unchanged.

DDx- perianal abscess/ anal fissure
external hemorrhoid (thrombosed?)


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1 Replies:

  • Well, I would more consider it to be a consequence of an anal tear that may be abcessing rather than an thrombosed hemorrhoid, the latter of which would have likely been associated with some historical symptoms and the timeframe a bit to brief as well. Folks who often engage in this practice regularly forego the necessary time for the internal sphincter to sufficiently relax, potentially resulting in mechanical trauma that initially appears as modest discomfort about 24 to 48 hours post-event. Since it was also mentioned that the pratice is performed both with and without lubricants, the absence of lubricant would further increase the risk of an anal tear. If it has begun to abcess, you'll know fairly soon whether it has to be drained. Having expressed my comments, I would now ask why you don't have a consult freely available from proctology since you're an ICU-based physician? Surely you must agree that the internet is an extremely poor choice by comparison, correct? Best regards, J Cottle, MD
    JCottleMD 580 Replies
    • January 6, 2009
    • 00:05 AM
    • 0
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